The medical care practitioner: development of a new healthcare professional in primary and acute secondary care in the UK

Vice-Chairman, Royal College of General Practitioners, London, and Visiting Professor of General Practice, University of Lincoln and Associate Director of Postgraduate General Practice Education, Trent Multiprofessional Deanery, UK

Abstract

There has been a demand over the last few years to increase the workforce in both primary and secondary care to meet the requirements of The NHS Plan 2000.1 The NHS Plan stated that staffing constraints, rather than lack of funding, posed the greatest threat to NHS modernisation.

Introduction

There has been a demand over the last few years to
increase the workforce in both primary and secondary
care to meet the requirements of The NHS Plan 2000.[1]
The NHS Plan stated that staffing constraints, rather
than lack of Funding, posed the greatest threat to NHS
modernisation. As a result there has been the development
of new and extended roles. This has often been
a localised response to address a particular need. The
titles of these new posts vary, leading to confusion and
lack of clarity of roles and responsibilities. This is a
very unsatisfactory situation with unregulated practitioners
providing care for patients, with varying degrees
of supervision. These roles may also lack the potential
for transferability and sustainability in the NHS.

There is a need to define the standards of education
and training for these emerging roles. To help address
these problems, the Royal College of General Practitioners
and the Royal College of Physicians have
worked with the National Practitioner Programme to
develop a competence and curriculum framework for
medical care practitioners. This role developed from
the physician assistant model in the United States.

Physician assistants

Physician assistants were developed in the United
States in the 1960s to ‘relieve a nationwide shortage
of doctors in primary care and to increase access to
health care for people in under-served areas’.[2] Physician
assistants undergo two years of training after a first degree and pass a national certifying examination.
They also have to complete 100 hours of continuing
education every two years and pass a recertification
examination every 6 years.[3]

What is a medical care
practitioner?

The medical care practitioner is defined as ‘a new
healthcare professional who, while not a doctor,works
to the medical model, with the attitudes, skills and
knowledge base to deliver holistic care and treatment
within the general medical and/or general practice
team under defined levels of supervision’.[4]

In primary care, the medical care practitioner role
will provide an opportunity to improve and develop
the skill mix in healthcare teams, whilst emphasising
the unique skills and knowledge of general practitioners
(GPs) and other healthcare professionals.

The competence and curriculum framework for
medical care practitioners outlines the standards, education
and assessment of these practitioners, providing
the basis for a qualification from a UK higher
education institution. It outlines the knowledge, skills
and core competences expected at qualification. It is
anticipated that a fully trained medical care practitioner
will deliver care and treatment at the level of a
doctor in their second foundation year.

What will medical care
practitioners do?

A medical care practitioner will be able to perform
many tasks that are currently carried out by doctors,
enabling doctors to concentrate on the complex problems
which require the particular skills and knowledge
of a GP or hospital consultant.

The medical care practitioner will be able to:

•take a detailed history, perform a physical examination
and develop a differential diagnosis within
the limits of their competence

•develop a patient management plan taking account
of the particular circumstances of the patient

Training and supervision

The training programme is 90 weeks with 3150 hours
of teaching, of which 1600 hours is designated as
clinical learning. This is broadly equivalent to a threeyear
degree programme. Entrants to the course will be
recruited mainly from science graduates, but it is also
open to existing health professionals. This is a new
profession and it is important that standards and the
level of competence are clearly defined, which will
enable criteria to be developed for statutory regulation.

Medical care practitioners will always work under
the supervision of a doctor and will only delegate tasks
which they are competent to perform in accordance
with guidance set out in the General Medical Council’s
document, Good Medical Practice.[5]

The recognition of clinical conditions beyond the
expertise of a medical care practitioner is a vital competence.
Medical care practitioners will be trained to
work to the medical model so that they will be able to
apply their knowledge and skills to the needs of the
individual patient, rather than working to predetermined
protocols. The document includes a model for
categorising clinical conditions on the basis of required
competence. Competences are elements performed to
a predetermined standard, which combine to create
professional capability in a defined role.[6] Using this
model there are conditions which a medical care
practitioner will be able to diagnose and treat; those
conditions which when already diagnosed can then be
managed by a medical care practitioner; those situations when referral to the supervising doctor is required,
and those conditions which a medical care practitioner
can monitor when this has been diagnosed and a
management plan developed by the supervising doctor.

Medical care practitioners and
physician assistants in England

The Changing Workforce Programme (now the
National Practitioner Programme) began piloting the
medical care practitioner role in South West London
and North East London in 2004.

In 2002, Tipton and Rowley Regis Primary Care
Trust in the Black Country recruited physician assistants
from the United States in response to problems of
recruitment of GPs. These physician assistants are
currently unregulated, and responsibility for their actions
is taken by the supervising doctor. Birmingham
University Health Services Management Centre has
evaluated this initiative.[7] The report emphasised the
need to retain the dependent practitioner status as this
was recognised as essential for patient-centred care.
Stewart and Catanzaro reviewed the experience of
12 US physician assistants working in Sandwell,
West Midlands.[8] They concluded that the physician
assistant model worked well in the UK. They suggested
‘this group of practitioners can provide a high standard
of care to patients as well as help to support the
medical multidisciplinary team’.

Conclusion

The development of the medical care practitioner role
should benefit both patients and other health professionals.
It will provide an opportunity to further
enhance the skill mix within the healthcare team. This
will allow doctors to be able to spend more time with
patients with multiple complex problems. It will give
patients more choice of healthcare professional and,
by having a national curriculum and competence
framework, medical care practitioners will achieve a
level of competence to agreed national standards
helping to ensure that patients receive high-quality
patient-centred care.

References

Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: The Stationery Office, 2000. The medical care practitioner 7